UTI Treatment for Males
All UTIs in males are considered complicated by definition and require 7-14 days of antibiotic treatment, with mandatory urine culture and susceptibility testing before starting empiric therapy. 1, 2
Obtain Urine Culture First (Mandatory)
- Always obtain urine culture with susceptibility testing before initiating antibiotics, as male UTIs have broader microbial spectrum and higher antimicrobial resistance rates compared to uncomplicated UTIs in women. 2
- Common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1, 2
First-Line Empiric Oral Antibiotics (While Awaiting Culture)
For empiric treatment, choose based on local resistance patterns:
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is recommended as first-line therapy if local resistance is <20%. 3, 4
- Fluoroquinolones are preferred alternatives if local resistance is <10%: 2, 3
- Ciprofloxacin 500-750 mg twice daily for 7 days, OR
- Levofloxacin 750 mg once daily for 5-7 days
Critical Advantage of Fluoroquinolones
- Fluoroquinolones have superior prostatic penetration, which is crucial since prostatitis cannot be excluded in most males with UTI symptoms. 2
Treatment Duration
- Minimum 7 days for all male UTIs. 2, 3
- Extend to 14 days when prostatitis cannot be excluded, which applies to most males with UTI symptoms, persistent symptoms, or systemic signs of infection. 1, 2, 3
Parenteral Therapy for Severe Presentations
Initiate IV antibiotics if the patient appears systemically ill, has pyelonephritis, or cannot tolerate oral therapy: 1, 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 antibiotics when clinically stable and afebrile for 48 hours, adjusting based on culture results. 2
Multidrug-Resistant Organisms
If patient has risk factors for resistant organisms (healthcare-associated infection, recent antibiotics, known ESBL producers), consider broader-spectrum agents: 1, 2
- 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
Critical Pitfalls to Avoid
- Never use amoxicillin or ampicillin empirically due to very high worldwide resistance rates and poor efficacy. 2
- Always consider prostatitis in males with UTI symptoms, as this requires 14 days of treatment rather than 7 days. 2
- Avoid trimethoprim-sulfamethoxazole if local resistance exceeds 20%. 2, 3
- Avoid fluoroquinolones if local resistance exceeds 10%. 2