Fosfomycin Use in a 60-Year-Old Male
Fosfomycin should NOT be used for a 60-year-old male with a UTI, as current guidelines explicitly recommend it only for uncomplicated cystitis in women, with insufficient efficacy data to support its use in men. 1
Guideline-Based Restrictions
The European Urology guidelines clearly state that fosfomycin is recommended only for uncomplicated cystitis in women and should not be used for pyelonephritis, complicated UTIs, or in men due to limited efficacy data for these conditions. 1 The guidelines further emphasize that fosfomycin is not recommended for routine use in men with UTIs, as clinical efficacy data is limited in this population. 1
Historical Context and Current Evidence
While the 2011 IDSA/ESMID guidelines listed fosfomycin as an appropriate choice for acute uncomplicated cystitis (without gender-specific restrictions), they noted inferior efficacy compared to standard short-course regimens based on FDA data. 2 However, the more recent 2025 European Urology guidelines have narrowed the indication specifically to women only. 1
Alternative Approaches for Men
For a 60-year-old male with a UTI, you should consider:
First-line options: Nitrofurantoin (100 mg twice daily for 5-7 days) or trimethoprim-sulfamethoxazole (if local resistance <20%) are appropriate choices. 2
Fluoroquinolones: Ciprofloxacin or levofloxacin for 7 days are highly efficacious, though they should be reserved for situations where other agents cannot be used due to their propensity for collateral damage. 2
Beta-lactams: Amoxicillin-clavulanate or cephalosporins (3-7 days) can be used when other recommended agents are not suitable, though they have inferior efficacy compared to other UTI antimicrobials. 2
Critical Caveat
UTIs in men are generally considered complicated by definition due to anatomical and physiological differences, making the choice of fosfomycin even more inappropriate, as it is specifically contraindicated for complicated UTIs. 1 Always obtain urine culture and susceptibility testing in male patients with UTIs to guide definitive therapy. 2