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

Treatment of UTI in Males

Treat all male UTIs with a 14-day course of antibiotics, as these are classified as complicated infections requiring longer therapy than in women. 1

Initial Diagnostic Steps

Before starting treatment, obtain urine culture and susceptibility testing to guide targeted therapy and evaluate for underlying urological abnormalities. 1 This is critical because male UTIs have a broader microbial spectrum and higher antimicrobial resistance rates compared to female UTIs. 1

Empiric Antibiotic Selection

First-Line Options (European Urology Guidelines)

Choose one of the following empiric regimens while awaiting culture results: 1

• Amoxicillin plus an aminoglycoside
• Second-generation cephalosporin plus an aminoglycoside
• Intravenous third-generation cephalosporin

Alternative Oral Option: Ciprofloxacin

Ciprofloxacin may be used ONLY when ALL of the following criteria are met: 1

• Local fluoroquinolone resistance rate is <10%
• Patient does not require hospitalization
• Entire treatment can be given orally
• Patient has anaphylaxis to β-lactam antibiotics

Critical caveat: A 2017 randomized trial demonstrated that 7-day ciprofloxacin was inferior to 14-day treatment in men (86% vs 98% cure rate), confirming the necessity of the full 14-day course. 1

When to AVOID Fluoroquinolones

Do not use fluoroquinolones empirically if: 1

• Patient is from a urology department
• Patient has used fluoroquinolones in the last 6 months
• Local fluoroquinolone resistance exceeds 10%

This is particularly important as fluoroquinolone resistance is increasingly common and these agents should be reserved for more invasive infections. 2

Treatment Duration Algorithm

Standard duration: 14 days when prostatitis cannot be excluded (which is most male UTIs). 1

Shortened to 7 days ONLY when: 1

• Patient is hemodynamically stable
• Patient has been afebrile for at least 48 hours
• No concern for prostatic involvement

The 14-day duration is necessary because male UTIs often involve prostatic tissue, requiring agents that penetrate prostatic tissue and secretions adequately. 3

Common Pathogens to Expect

Male UTIs are caused by: 1

• E. coli (most common, ~48%)
• Proteus spp.
• Klebsiella spp.
• Pseudomonas spp. (especially in elderly)
• Serratia spp.
• Enterococcus spp.

Essential Management Beyond Antibiotics

Evaluate and manage underlying urological abnormalities, as these are present in most male UTIs and must be addressed to prevent recurrence. 1 This includes assessing for structural or functional abnormalities of the urinary tract that contribute to infection. 1

Follow-Up Strategy

Monitor for symptom resolution and consider follow-up urine culture in all cases, as male UTIs are classified as complicated infections. 1 Address any identified underlying abnormalities to prevent recurrence. 1

Critical Pitfalls to Avoid

• Never treat for only 7 days as standard practice - this is inadequate for male UTIs when prostatitis cannot be excluded. 1
• Never use fluoroquinolones without checking local resistance patterns - they should only be used when resistance is <10%. 1
• Never skip urine culture - susceptibility testing is essential given higher resistance rates in male UTIs. 1
• Never ignore underlying urological abnormalities - failure to address these leads to recurrent infections. 1