What are the treatment options for uncomplicated urinary tract infections (UTIs) in men?

Treatment of Uncomplicated UTIs in Men

For uncomplicated UTIs in men, prescribe trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days as first-line therapy, unless local resistance exceeds 20%, in which case use a fluoroquinolone for 7 days. 1, 2

First-Line Antibiotic Selection

• Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 7 days is the preferred first-line treatment according to European Association of Urology guidelines 1, 2

• Avoid TMP-SMX if local E. coli resistance exceeds 20% 1

• Fluoroquinolones (ciprofloxacin or levofloxacin) serve as appropriate alternatives when local susceptibility patterns permit their use 1, 2

• Nitrofurantoin may be considered for uncomplicated lower UTIs, though it is less commonly used due to concerns about inadequate prostate penetration 2

• TMP-SMX is FDA-approved for UTIs caused by susceptible E. coli, Klebsiella, Enterobacter, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 3

Treatment Duration Algorithm

• Standard duration: 7 days minimum for all uncomplicated UTIs in men 1, 2, 4

• Extend to 14 days when:

  • Prostatitis cannot be excluded 1, 2
  • Persistent symptoms remain during treatment 1
  • Systemic signs of infection are present 1

When to Escalate to Parenteral Therapy

• Initiate IV antibiotics (ciprofloxacin, levofloxacin, ceftriaxone, cefepime, or piperacillin-tazobactam) if the patient appears systemically ill or has pyelonephritis 1

Critical Considerations Specific to Male UTIs

• All UTIs in males are considered complicated by definition and require more thorough evaluation than female UTIs 2

• UTIs in males are frequently associated with underlying urological abnormalities or complicating factors 2

• Always obtain urine culture and susceptibility testing before initiating treatment to guide antibiotic selection 4

• Consider urethritis and prostatitis as alternative or concurrent diagnoses in men presenting with UTI symptoms 4

Common Pitfalls to Avoid

• Do not use treatment courses shorter than 7 days in men, as this is inadequate 2

• Do not fail to consider prostatitis as a complicating factor that may require longer treatment (up to 14 days) 2

• Do not overlook underlying structural or functional abnormalities that predispose to infection 2

• Do not use TMP-SMX empirically in areas with high resistance rates (>20%) without culture guidance 1

Follow-Up Management

• Post-treatment urine cultures are not routinely needed if symptoms resolve completely 1, 2

• If symptoms persist or recur within 2 weeks:

  • Perform urine culture and antimicrobial susceptibility testing 2
  • Consider retreatment with a 7-day regimen using a different antibiotic 2
  • Pursue imaging or urological evaluation for recurrent infections or inadequate response to appropriate therapy 2