What is the recommended treatment for urinary tract infections (UTIs) in men?

Treatment of Urinary Tract Infections in Men

All UTIs in men should be treated as complicated infections with a 14-day course of antibiotics when prostatitis cannot be excluded, though a 7-day course may be appropriate for hemodynamically stable patients who have been afebrile for at least 48 hours. 1, 2

Initial Diagnostic Approach

Always obtain urine culture and susceptibility testing before starting antibiotics to guide appropriate therapy, as male UTIs have a broader microbial spectrum and higher antimicrobial resistance rates than uncomplicated UTIs. 1, 2 Common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1, 2

Empiric Antibiotic Selection

First-Line Options for Systemic Symptoms:

• Amoxicillin plus an aminoglycoside 1, 2
• Second-generation cephalosporin plus an aminoglycoside 1, 2
• Intravenous third-generation cephalosporin 1, 2

Oral Therapy Considerations:

• Fluoroquinolones (ciprofloxacin) may be used ONLY if local resistance rates are <10% 1, 2
• Never use fluoroquinolones if the patient has used them in the last 6 months 1, 2
• Do not use fluoroquinolones empirically in patients from urology departments 2
• Trimethoprim-sulfamethoxazole is FDA-approved for UTIs caused by susceptible E. coli, Klebsiella, Enterobacter, Morganella, and Proteus species 3

Treatment Duration: Critical Evidence Divergence

There is contradictory evidence regarding optimal treatment duration:

The 14-Day Standard:

• A 2017 randomized trial showed 14-day ciprofloxacin was superior to 7-day treatment in men (98% vs 86% cure rate) 2
• European Urology guidelines recommend 14 days when prostatitis cannot be excluded 1, 2

The 7-Day Alternative:

• A 7-day course may be considered when the patient is hemodynamically stable and afebrile for ≥48 hours 1, 2
• Studies by Drekonja et al. found 7-day treatment with fluoroquinolones or trimethoprim-sulfamethoxazole was non-inferior to 14-day treatment 1
• A 2019 outpatient database study showed no clinical benefit to treating longer than 7 days, and longer treatment was actually associated with increased recurrence in men without complicating conditions 4
• A 2016 study demonstrated males with UTI may be successfully treated with 5 days of levofloxacin 750mg daily 5

Given this conflicting evidence, the safest approach is to start with 14 days when prostatitis cannot be excluded, but consider shortening to 7 days for uncomplicated cases in stable, afebrile patients. 1, 2

Special Management Situations

Catheter-Associated UTIs:

• Remove or change the catheter when possible 1

Systemic Symptoms:

• Consider initial parenteral therapy until clinical improvement occurs 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 1
• Using fluoroquinolones empirically in areas with resistance rates >10% 1, 2
• Using fluoroquinolones in patients who received them within 6 months 1, 2
• Not considering prostatitis as a complication, which requires longer treatment 1, 2
• Treating all male UTIs with prolonged courses when shorter durations may be appropriate for certain stable patients 1, 4
• Not addressing underlying anatomical or functional abnormalities 1, 2

Tailoring Therapy

Adjust antibiotic selection based on culture and susceptibility results once available 1, 2 The increasing prevalence of antibiotic resistance, particularly in E. coli, necessitates culture-guided therapy rather than prolonged empiric treatment. 6, 7