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

Treatment of Urinary Tract Infections in Males

First-Line Antibiotic Recommendations

For males with urinary tract infections, trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7-14 days is the recommended first-line treatment, with 14 days preferred when prostatitis cannot be excluded. 1, 2, 3

Primary Treatment Options

• Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily is the preferred first-line agent, as it effectively targets common uropathogens including E. coli, Klebsiella, Enterobacter, and Proteus species 1, 2, 3, 4

• Nitrofurantoin 100 mg twice daily for 7-14 days is an alternative first-line option 2

• Treatment duration should be 14 days when prostatitis cannot be excluded, which is common in male UTIs due to anatomical considerations 2, 5, 3

Alternative Oral Agents

• Cefpodoxime 200 mg twice daily for 7-14 days can be used when TMP-SMX cannot be used or resistance is suspected 2, 3

• Ceftibuten 400 mg once daily for 10 days is another oral cephalosporin alternative 3

• These cephalosporins are recommended only when local E. coli resistance is <20% 1

Fluoroquinolone Use: Important Restrictions

Fluoroquinolones should only be used as second-line agents under specific conditions:

• Ciprofloxacin 500 mg twice daily or levofloxacin 750 mg once daily may be considered only when: 2, 5

  • Local resistance rates are <10% 2, 5, 6
  • Patient has no history of fluoroquinolone use in the past 6 months 2, 5
  • Patient is not from a urology department 5

• The FDA has issued warnings against fluoroquinolones for uncomplicated UTIs due to unfavorable risk-benefit ratios 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 need for longer duration 5, 3

Treatment Duration Algorithm

Standard duration: 14 days when prostatitis cannot be excluded (which is the usual clinical scenario) 1, 2, 5, 3

Shorter duration (7 days) may be considered only if:

• Patient becomes afebrile within 48 hours 2, 5, 3
• Clear clinical improvement is documented 2, 5, 3
• Prostatitis has been definitively excluded 2

Essential Diagnostic Steps

• Obtain urine culture and antimicrobial susceptibility testing before initiating therapy to guide targeted treatment 1, 2, 5, 3

• Male UTIs are classified as complicated infections due to anatomical factors and have a broader microbial spectrum with higher likelihood of antimicrobial resistance 2, 5, 3

• Common pathogens include E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 2, 5, 3

Monitoring and Adjustment

• Reassess after 48-72 hours of empiric therapy to evaluate clinical response 2

• Adjust therapy based on culture and susceptibility results when available 2

• Consider evaluation for underlying structural or functional abnormalities that may contribute to infection 2, 5, 3

Critical Pitfalls to Avoid

• Never use treatment courses shorter than 7 days unless prostatitis has been definitively excluded 2, 3

• Avoid fluoroquinolones as empiric therapy if local resistance exceeds 10% or patient has recent fluoroquinolone exposure 2, 5, 6

• Do not fail to obtain pre-treatment urine culture, as this complicates management if empiric therapy fails 5, 3

• Never treat asymptomatic bacteriuria in men without specific indications, as this increases resistant organism development 2

• Inadequate treatment duration leads to persistent or recurrent infection, particularly when prostate involvement is present 3

Treatment Failure Management

• If treatment failure occurs, assume the organism is not susceptible to the original agent 1

• Retreatment with a 7-day regimen using another agent should be considered based on susceptibility testing 1

• For multidrug-resistant organisms, consider parenteral options such as ceftazidime-avibactam 2.5g three times daily or meropenem-vaborbactam 2g three times daily 3