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

Treatment of Urinary Tract Infection in Adult Males

Adult males with UTI should be treated with 7 days of fluoroquinolone therapy (ciprofloxacin 500-750 mg twice daily or levofloxacin 750 mg once daily) as first-line treatment, with treatment extended to 14 days only when prostatitis cannot be excluded. 1

Classification and Initial Approach

All UTIs in adult males are classified as complicated UTIs by definition, regardless of the presence of other complicating factors, because male gender itself is considered a complicating factor. 1

• Obtain urine culture and susceptibility testing before initiating antibiotics to confirm the causative organism and guide therapy adjustments. 1, 2
• Evaluate for underlying urological abnormalities (obstruction, incomplete voiding, recent instrumentation) that may complicate treatment. 1
• Consider prostatitis in the differential diagnosis, as this will affect treatment duration. 1

First-Line Antibiotic Therapy

Fluoroquinolones are the preferred first-line agents provided local resistance rates are below 10%:

• Ciprofloxacin 500-750 mg orally twice daily for 7 days is the primary recommendation. 1, 3
• Levofloxacin 750 mg orally once daily for 5-7 days is an equally effective alternative. 1, 3

The evidence supporting 7-day fluoroquinolone therapy in men is robust: a well-powered RCT by Drekonja et al. demonstrated that 7-day courses of fluoroquinolones or trimethoprim-sulfamethoxazole were non-inferior to 14-day courses in men with complicated UTI, despite high rates of anatomic abnormalities. 1

Alternative Treatment Options

When fluoroquinolones are contraindicated or resistance patterns preclude their use:

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 14 days (longer duration required for non-fluoroquinolone agents). 1, 4
• Cefpodoxime 200 mg twice daily for 10 days or ceftibuten 400 mg once daily for 10 days. 1
• Nitrofurantoin for 7 days is an option for uncomplicated lower UTI in men. 2

Treatment Duration Considerations

The standard duration is 7 days for uncomplicated presentations with prompt symptom resolution. 1

• Extend to 14 days when prostatitis cannot be excluded, as inadequate treatment of occult prostatitis leads to recurrence. 1
• For patients with delayed clinical response beyond 72 hours, consider extending to 10-14 days or switching antibiotics based on culture results. 5
• Patients who are hemodynamically stable and afebrile for at least 48 hours may be considered for the shorter 7-day course. 1

Special Clinical Scenarios

For catheter-associated UTI:

• Replace the catheter if it has been in place for ≥2 weeks before obtaining culture from the freshly placed catheter. 5
• Remove catheters as soon as clinically appropriate to reduce infection risk. 5

For multidrug-resistant organisms:

• Aminoglycosides (gentamicin 5 mg/kg daily or amikacin 15 mg/kg daily) may be required for resistant strains. 1, 5
• Consider carbapenems or novel broad-spectrum agents only when culture results confirm multidrug-resistant organisms. 1

Monitoring and Follow-Up

• Assess clinical response within 72 hours of treatment initiation. 5
• If symptoms persist beyond 72 hours, obtain repeat culture and consider alternative antibiotics or extended duration based on susceptibility testing. 5
• Address any underlying urological abnormalities that predispose to recurrent infections. 5

Critical Pitfalls to Avoid

Do not automatically default to 14-day therapy for all male UTIs—this outdated approach increases antimicrobial resistance and adverse effects without improving outcomes in men with uncomplicated presentations. 1 One older subgroup analysis suggested 7-day ciprofloxacin was inferior to 14-day therapy in men, but this was contradicted by the larger, adequately powered Drekonja study showing non-inferiority of 7-day courses. 1

Do not use fluoroquinolones empirically if local resistance exceeds 10% or if the patient has recent fluoroquinolone exposure. 1, 6

Do not overlook prostatitis—failure to extend treatment to 14 days when prostatitis is suspected leads to treatment failure and recurrence. 1