What is the recommended treatment for a male urinary tract infection (UTI)?

Treatment of Male Urinary Tract Infections

For male UTIs, obtain a urine culture before starting antibiotics, then treat with either fluoroquinolones (if local resistance <10%) or trimethoprim-sulfamethoxazole for 7 days in hemodynamically stable, afebrile patients without prostatitis, or 14 days when prostatitis cannot be excluded. 1, 2

Initial Diagnostic Steps

• Always obtain urine culture and susceptibility testing before initiating therapy to guide appropriate antibiotic selection, as all male UTIs are classified as complicated UTIs with broader microbial spectrums and higher antimicrobial resistance rates 1, 2
• The common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1, 3

Empiric Antibiotic Selection

For Patients with Systemic Symptoms or Requiring Hospitalization:

• First-line parenteral options include: amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an intravenous third-generation cephalosporin 1, 2

For Oral Outpatient Therapy:

• Fluoroquinolones (ciprofloxacin or levofloxacin) are appropriate when local resistance rates are <10% 1, 2, 4
• Trimethoprim-sulfamethoxazole is an effective alternative 3, 4
• Do not use fluoroquinolones if the patient has used them in the last 6 months or is from a urology department 1, 2

Treatment Duration

Standard Approach:

• 14 days of treatment when prostatitis cannot be excluded 1, 2
• 7 days of treatment is non-inferior to 14 days for afebrile men without complicating conditions (hemodynamically stable and afebrile for at least 48 hours) 1, 4, 5

Evidence Supporting Shorter Duration:

• A high-quality randomized controlled trial demonstrated that 7 days of ciprofloxacin or trimethoprim-sulfamethoxazole achieved 93.1% symptom resolution compared to 90.2% with 14 days (meeting noninferiority criteria) 4
• Recurrence rates were similar between 7-day (9.9%) and 14-day (12.9%) treatment groups 4
• Outpatient database studies confirm that longer treatment duration does not reduce recurrence and may actually increase it in men without complicating conditions 5

Special Situations

Catheter-Associated UTIs:

• Remove or change the catheter when possible alongside antibiotic therapy 1

Structural Abnormalities:

• Management of underlying urological abnormalities is mandatory alongside antibiotic therapy 1, 2
• Consider imaging studies if recurrent infections occur 1

Critical Pitfalls to Avoid

• Failing to obtain urine culture before starting antibiotics leads to inappropriate empiric therapy selection 1, 2
• Using fluoroquinolones empirically in areas with high resistance rates (>10%) results in treatment failure 1, 2
• Not considering prostatitis as a complication, which requires the full 14-day course rather than 7 days 1, 2
• Overtreating with prolonged courses when 7 days is sufficient for uncomplicated cases, unnecessarily increasing adverse events (20.6% vs 24.3%), resistance risk, and costs 4, 5
• Not tailoring therapy based on culture results once available 1

Follow-Up Management

• Tailor antibiotic therapy based on culture and susceptibility results once available 1, 2
• Monitor for symptom resolution and consider follow-up urine culture in complicated cases 2
• Address any identified underlying anatomical or functional abnormalities to prevent recurrence 1, 2