Antibiotic Treatment for Male UTI
All UTIs in males are considered complicated and require 7-14 days of treatment with mandatory urine culture before starting antibiotics
All male UTIs require urine culture with susceptibility testing before initiating empiric therapy, as they have a broader microbial spectrum and higher antimicrobial resistance rates than female uncomplicated UTIs. 1
Critical First Step: Obtain Urine Culture
- Urine culture with susceptibility testing is mandatory before starting antibiotics to guide targeted therapy 1
- Common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1
- Male UTIs are defined as complicated by European Urology guidelines and require longer treatment than female uncomplicated cystitis 1
First-Line Empiric Oral Antibiotics (While Awaiting Culture)
Fluoroquinolones (Preferred if local resistance <10%)
- Ciprofloxacin 500-750 mg twice daily for 7 days 1
- Levofloxacin 750 mg once daily for 5-7 days 1
- Fluoroquinolones have superior prostatic penetration, which is critical since prostatitis cannot be excluded in most male UTI presentations 1
Alternative: Trimethoprim-Sulfamethoxazole
- Trimethoprim-sulfamethoxazole 160/800 mg (1 DS tablet) twice daily for 7-14 days 1, 2
- Avoid if local resistance exceeds 20% 1
- FDA-approved dosing for UTI is 1 DS tablet every 12 hours for 10-14 days 2
- Recent evidence supports this as first-line for men with uncomplicated UTI for 7 days 3
Nitrofurantoin
- Nitrofurantoin 100 mg twice daily for 7 days 3
- Supported by recent evidence as first-line option for men 3
- Note: Nitrofurantoin has poor tissue penetration and should be avoided if prostatitis is suspected 1
Treatment Duration Algorithm
- Standard duration: 7 days minimum for uncomplicated male UTI 1
- Extended to 14 days when prostatitis cannot be excluded, which is common in males with UTI symptoms 1
- Consider prostatitis in all males with UTI symptoms, as this requires 14 days of treatment 1
Parenteral Options for Severe Presentations
When to Use IV Therapy
- Patient appears systemically ill or has pyelonephritis 1
IV Antibiotic Options
- Ciprofloxacin 400 mg IV twice daily 1
- Levofloxacin 750 mg IV once daily 1
- Ceftriaxone 1-2 g IV once daily 1
- Cefepime 1-2 g IV twice daily 1
- Piperacillin-tazobactam 2.5-4.5 g IV three times daily 1
Step-Down Strategy
- Transition to oral antibiotics when clinically stable and afebrile for 48 hours 1
- Adjust antibiotic selection based on culture and susceptibility results 1
Critical Pitfalls to Avoid
- Never use amoxicillin or ampicillin empirically due to very high worldwide resistance rates and poor efficacy 1
- Do not use short-course therapy (3-5 days) as recommended for women—males require minimum 7 days 4, 1
- Always consider prostatitis in males with UTI symptoms, as this requires 14 days of treatment and fluoroquinolones have better prostatic penetration 1
- Avoid nitrofurantoin if prostatitis is suspected due to poor tissue penetration 1
Multidrug-Resistant Organisms
Risk Factors Requiring Broader Coverage
- Prior fluoroquinolone use 5
- Recent hospitalization or healthcare exposure 6
- History of resistant isolates 3
Parenteral Options for MDR Organisms
- Ceftolozane-tazobactam 1.5 g IV three times daily 1
- Ceftazidime-avibactam 2.5 g IV three times daily 1
- Meropenem 1 g IV three times daily 1
- Aminoglycosides: Gentamicin 5 mg/kg IV once daily or Amikacin 15 mg/kg IV once daily are effective alternatives, especially with prior fluoroquinolone resistance 1