Are males still considered to have complicated urinary tract infections (UTIs) according to the IDSA guidelines?

Male Sex and Complicated UTI Classification

According to the most recent 2024 European Association of Urology (EAU) guidelines, male sex is still explicitly considered a factor associated with complicated urinary tract infections. 1

Current Guideline Position

The 2024 EAU guidelines clearly list "Urinary tract infection in males" as one of the common factors associated with complicated UTIs in Table 7 of their comprehensive recommendations. 1 This classification persists in the most recent guideline update, maintaining the traditional approach that UTIs in men warrant different management considerations than uncomplicated cystitis in women.

Rationale for This Classification

The designation of male UTIs as complicated stems from several key factors:

• Anatomical considerations: Most men with UTI have functional or anatomic abnormalities of the genitourinary tract, with prostatic hypertrophy being a major predisposing factor 2

• Risk of prostatic involvement: The 2024 EAU guidelines specifically recommend treatment duration of 14 days for men when prostatitis cannot be excluded, compared to 7 days when it can be ruled out 1

• Different microbial spectrum: The bacterial species and antimicrobial resistance patterns differ from uncomplicated UTIs in women 1

Important Clinical Nuances

However, emerging evidence suggests this blanket classification may be overly broad:

• A 2023 systematic review found that short-duration therapy (7 days) produces similar clinical success as long-duration therapy (10-14 days) in men with complicated UTI, even with high rates of anatomic abnormalities 1

• An outpatient database study of 637 male UTI visits demonstrated no clinical benefit to treating longer than 7 days in men without complicating conditions (prostatitis, pyelonephritis, urologic abnormalities, immunocompromising conditions) 3

• One subgroup analysis showed 7-day ciprofloxacin was inferior to 14-day treatment in men, but this was contradicted by a larger, adequately powered study showing non-inferiority of 7-day courses 1

Practical Management Algorithm

For male patients with UTI, stratify as follows:

1. Assess for true complicating factors beyond male sex alone:

   • Urinary obstruction at any site 1
   • Prostatic symptoms suggesting prostatitis 1
   • Recent instrumentation 1
   • Immunosuppression or diabetes 1
   • Presence of foreign body/catheter 1

2. If complicating factors present:

   • Obtain urine culture and susceptibility testing (mandatory) 1
   • Treat for 14 days if prostatitis cannot be excluded 1
   • Use combination therapy for systemic symptoms (amoxicillin plus aminoglycoside, second-generation cephalosporin plus aminoglycoside, or IV third-generation cephalosporin) 1

3. If no complicating factors beyond male sex:

   • Consider 7-day treatment course as potentially adequate 1, 3
   • Still obtain culture given higher resistance risk 1

Critical Pitfall to Avoid

Do not automatically prescribe 14-day courses for all male UTIs. The evidence increasingly supports shorter durations (7 days) in men without evidence of prostatitis, upper tract involvement, or structural abnormalities. 1, 3 Longer treatment durations increase resistance risk, adverse events, and costs without demonstrated benefit in uncomplicated cases. 3

The 2024 EAU guidelines maintain male sex as a complicated UTI factor, but clinical judgment should determine whether the individual patient truly requires extended therapy or can be managed with shorter courses when complicating features are absent.