What antibiotics are recommended for treating urinary tract infections (UTIs) in males?

Antibiotic Treatment for UTI in Males

UTIs in males are classified as complicated infections requiring 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

Key Classification Principle

• All UTIs in males are considered complicated by definition, which fundamentally changes the treatment approach compared to female UTIs 1, 2
• The microbial spectrum is broader than uncomplicated UTIs, with higher antimicrobial resistance rates involving E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1, 2

Empiric Antibiotic Selection

First-Line Regimens (Strong Recommendation)

• Amoxicillin plus an aminoglycoside 1, 2
• Second-generation cephalosporin plus an aminoglycoside 1, 2
• Intravenous third-generation cephalosporin (such as ceftriaxone 1-2g daily or cefotaxime 2g three times daily) 1, 2

Fluoroquinolone Considerations (Use With Caution)

• Ciprofloxacin or levofloxacin may ONLY be used when ALL of the following criteria are met: 2

  • Local fluoroquinolone resistance is <10% 1, 2
  • Patient does not require hospitalization 2
  • Patient has anaphylaxis to β-lactam antimicrobials 2
  • Entire treatment can be given orally 2

• Avoid fluoroquinolones empirically if: 2

  • Patient is from a urology department 2
  • Patient has used fluoroquinolones in the last 6 months 2

Treatment Duration Algorithm

Standard Duration

• 14 days when prostatitis cannot be excluded (which applies to most male UTIs) 1, 2

Shortened Duration (7 days) - Only When ALL Criteria Met:

• Patient is hemodynamically stable 1, 2
• Patient has been afebrile for at least 48 hours 1, 2
• Relative contraindications exist to the antibiotic being administered 1
• No evidence of prostatic involvement 1

Essential Diagnostic Steps

• Obtain urine culture and susceptibility testing BEFORE initiating therapy 2
• Tailor initial empiric therapy based on culture results and switch to oral antimicrobial agent appropriate for the isolated uropathogen 1
• Evaluate for underlying urological abnormalities (obstruction, foreign body, incomplete voiding, vesicoureteral reflux) that require concurrent management 1, 2

Critical Pitfalls to Avoid

• Do not treat male UTIs with short 3-5 day courses commonly used in women—this is inadequate for males 1, 2
• Do not use fluoroquinolones as routine first-line empiric therapy given resistance concerns and FDA warnings 2
• Do not neglect to address underlying urological abnormalities, as appropriate management of these factors is mandatory for treatment success 1, 2
• Do not assume uncomplicated UTI exists in males—by definition, male gender makes the infection complicated 1

Specific Oral Regimens (When Appropriate)

For stable outpatients meeting criteria for oral therapy and with confirmed susceptibility:

• Ciprofloxacin 500-750 mg twice daily for 7-14 days (only if resistance <10%) 1
• Levofloxacin 750 mg once daily for 5-14 days (only if resistance <10%) 1, 3
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days (based on susceptibility) 1

Evidence Quality Note

While the 2024 European Association of Urology guidelines provide the strongest current recommendations 1, 2, a 2021 systematic review found insufficient high-quality RCT evidence to make definitive recommendations about optimal antibiotic type and duration specifically for male UTIs 4. However, a 2016 study demonstrated that 5-day levofloxacin courses achieved similar clinical success rates to 10-day courses in males with complicated UTIs 5, though the guideline-recommended 14-day duration remains standard when prostatitis cannot be excluded 1, 2.