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

Antibiotic Treatment for Male UTI

For male UTIs, obtain a urine culture before starting empiric therapy with ciprofloxacin 500-750 mg twice daily for 7-14 days (preferably 14 days when prostatitis cannot be excluded), or use trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days if fluoroquinolone resistance exceeds 10% locally. 1, 2

Critical First Step: Always Obtain Urine Culture

• All male UTIs are classified as complicated infections by definition and require mandatory urine culture with susceptibility testing before initiating antibiotics. 1, 2
• Male UTIs have a broader microbial spectrum than female cystitis, including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp., with higher antimicrobial resistance rates. 1, 2
• Men with UTI symptoms should always receive antibiotics (unlike women where delayed treatment may be considered), and clinicians must consider prostatitis and urethritis as alternative or concurrent diagnoses. 3

First-Line Empiric Oral Antibiotics

Fluoroquinolones (if local resistance <10%):

• Ciprofloxacin 500-750 mg twice daily for 7-14 days 1
• Levofloxacin 750 mg once daily for 5-7 days 1
• Do NOT use fluoroquinolones if the patient is from a urology department, has used fluoroquinolones in the last 6 months, or if local resistance exceeds 10%. 2

Alternative: Trimethoprim-Sulfamethoxazole:

• Trimethoprim-sulfamethoxazole 160/800 mg (Bactrim DS) twice daily for 7-14 days 1, 4, 3
• Avoid if local E. coli resistance exceeds 20% 1
• FDA-approved for UTIs caused by susceptible E. coli, Klebsiella, Enterobacter, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 5

Other Alternatives:

• Nitrofurantoin 100 mg twice daily for 7 days (though less commonly recommended for males) 3
• Trimethoprim 200 mg twice daily for 7 days 3

Treatment Duration: The 14-Day Rule

• Standard minimum duration is 7 days, but 14 days is strongly recommended when prostatitis cannot be excluded—which is common in males with UTI symptoms. 1, 2
• A 2017 randomized trial demonstrated that 7-day ciprofloxacin was inferior to 14-day treatment in men (86% vs 98% cure rate), confirming the superiority of longer treatment. 2
• Fluoroquinolones have superior prostatic penetration, making them preferred when prostatitis is suspected. 1
• Shorter 7-day courses may only be considered when the patient is hemodynamically stable and afebrile for at least 48 hours. 2

Parenteral Options for Severe Presentations

If systemically ill, signs of pyelonephritis, or unable to tolerate oral therapy:

• 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

Transition to oral antibiotics when:

• Clinically stable and afebrile for 48 hours 1
• Adjust selection based on culture and susceptibility results 1

Special Considerations for Multidrug-Resistant Organisms

If risk factors for resistant organisms exist (prior fluoroquinolone use, recent hospitalization, catheterization):

• 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 (especially effective with prior fluoroquinolone resistance) 1

Critical Pitfalls to Avoid

• Never use amoxicillin or ampicillin empirically—they have very high worldwide resistance rates and poor efficacy for UTIs. 1, 4
• Do not use 3-day regimens studied in women—these are inadequate for male patients. 4, 3
• β-lactams (including amoxicillin-clavulanate) generally have inferior efficacy and more adverse effects compared to other UTI antimicrobials. 4
• Always consider prostatitis in males with UTI symptoms, as this requires 14 days of treatment. 1

Renal Dose Adjustments for Trimethoprim-Sulfamethoxazole

• CrCl >30 mL/min: standard dose (160/800 mg twice daily) 4
• CrCl 15-30 mL/min: reduce to half-dose (single-strength tablet or half of double-strength) 4
• CrCl <15 mL/min: consider half-dose or alternative agent 4
• Monitor electrolytes regularly as trimethoprim can cause hyperkalemia, and ensure adequate hydration (at least 1.5 liters daily) to prevent crystalluria. 4

Follow-Up and Monitoring

• Adjust antibiotic selection based on culture and susceptibility results when available 1, 2
• Monitor for resolution of symptoms and consider follow-up urine culture in complicated cases 2
• Evaluate for underlying urological abnormalities or complicating factors that may require management 2