Treatment Recommendations for UTI in Males
For males with UTI, treat with trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days as first-line therapy, or use a fluoroquinolone (ciprofloxacin 500-750 mg twice daily or levofloxacin 750 mg once daily) for 7 days if local resistance patterns permit. 1, 2
Critical Distinction: All Male UTIs Are Complicated
- UTIs in males are considered complicated by definition and require longer treatment duration (7-14 days) compared to uncomplicated female cystitis 2
- The broader microbial spectrum and higher antimicrobial resistance rates in males necessitate a different approach than uncomplicated female UTIs 2
Mandatory First Step: Obtain Urine Culture
- Urine culture with susceptibility testing is mandatory before initiating empiric therapy in all males with UTI 2
- This is non-negotiable because male UTIs have a broader pathogen spectrum including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 2
- Culture results should guide adjustment of empiric therapy once available 3
First-Line Empiric Antibiotic Options
Trimethoprim-Sulfamethoxazole (Preferred in Guidelines)
- Dose: 160/800 mg twice daily for 7 days 1
- This is the specifically recommended regimen for males in the 2024 European Association of Urology guidelines 1
- Avoid if local resistance exceeds 20% 1, 2
- FDA-approved for UTI treatment in males 4
Fluoroquinolones (Alternative First-Line)
- Ciprofloxacin 500-750 mg twice daily for 7 days 2
- Levofloxacin 750 mg once daily for 5-7 days 2, 5
- Use only if local resistance is <10% 2
- Fluoroquinolones have superior prostatic penetration, which is critical since prostatitis cannot be excluded in most males with UTI symptoms 2, 6
- FDA-approved for complicated UTI treatment 5
Nitrofurantoin (Alternative)
- Dose: 100 mg twice daily for 7 days 3
- Less commonly recommended for males but can be used as an alternative 3
Treatment Duration Algorithm
Standard duration: 7 days minimum 1, 2, 3
Extend to 14 days when: 2
- Prostatitis cannot be excluded (common in males with UTI symptoms)
- Patient has persistent symptoms
- Systemic signs of infection are present
Critical Pitfall: Consider Prostatitis
- Always consider prostatitis in males presenting with UTI symptoms, as this requires 14 days of treatment 2
- Fluoroquinolones are preferred when prostatitis is suspected due to better prostatic tissue penetration 2, 6
- Symptoms suggesting prostatitis include perineal pain, obstructive voiding symptoms, or systemic symptoms 6
Severe Presentations Requiring Parenteral Therapy
Initiate IV antibiotics if the patient appears systemically ill or has pyelonephritis: 2
- Ciprofloxacin 400 mg IV twice daily
- Levofloxacin 750 mg IV once daily
- Ceftriaxone 1-2 g IV once daily
- Cefepime 1-2 g IV twice daily
- Piperacillin-tazobactam 2.5-4.5 g IV three times daily
Transition to oral therapy when: 2
- Clinically stable
- Afebrile for 48 hours
- Adjust based on culture and susceptibility results
Multidrug-Resistant Organisms
If patient has risk factors for resistant organisms (prior antibiotic use, healthcare exposure, recent hospitalization), consider broader-spectrum agents: 2, 7
- Ceftolozane-tazobactam 1.5 g IV three times daily
- Ceftazidime-avibactam 2.5 g IV three times daily
- Meropenem 1 g IV three times daily
- Aminoglycosides: gentamicin 5 mg/kg IV once daily or amikacin 15 mg/kg IV once daily 2
What NOT to Use
Never use amoxicillin or ampicillin empirically due to very high worldwide resistance rates and poor efficacy 2
Additional Considerations
- Always consider urethritis as an alternative diagnosis in males with dysuria, particularly in sexually active men 3
- Symptomatic treatment alone (without antibiotics) is NOT appropriate for males, unlike in some female patients with mild uncomplicated cystitis 3
- Post-treatment urine cultures are not routinely needed if symptoms resolve 1