What is the first-line treatment for urinary tract infections (UTIs) in men?

First-Line Treatment for UTI in Men

For men with urinary tract infections, trimethoprim-sulfamethoxazole (160/800 mg twice daily) for 14 days is the recommended first-line treatment when local resistance rates are acceptable, with nitrofurantoin (100 mg twice daily) as an alternative first-line option. 1, 2

Classification and Diagnostic Approach

• All UTIs in men are classified as complicated infections due to anatomical considerations, requiring longer treatment duration and broader antimicrobial coverage than uncomplicated UTIs in women 3, 1, 2

• Obtain urine culture and susceptibility testing before initiating antibiotics to guide targeted therapy and allow for adjustment if empiric treatment fails 3, 1, 2

• The microbial spectrum is broader in male UTIs, with common pathogens including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 3, 1, 2

First-Line Empiric Treatment Options

Preferred agents:

• Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 14 days is the primary first-line choice 1, 2, 4
• Nitrofurantoin 100 mg twice daily for 14 days is an equally acceptable first-line option 2

Alternative oral agents when TMP-SMX cannot be used:

• Cefpodoxime 200 mg twice daily for 10-14 days 1, 2
• Ceftibuten 400 mg once daily for 10-14 days 1

Treatment Duration: A Critical Decision Point

The standard duration is 14 days when prostatitis cannot be excluded, which is the typical scenario in male UTIs 3, 1, 2

A shorter 7-day course may be considered only when:

• The patient is hemodynamically stable 3, 2
• The patient has been afebrile for at least 48 hours 3, 2
• Prostatitis has been definitively excluded 2

However, recent high-quality evidence shows that 7-day treatment is inferior to 14-day treatment in men: a 2017 randomized trial demonstrated cure rates of only 86% with 7-day ciprofloxacin versus 98% with 14-day treatment 3

Fluoroquinolone Use: When and When Not

Ciprofloxacin should be reserved as a second-line agent and used only when ALL of the following criteria are met: 3, 2

• Local resistance rate is <10% 3, 2
• Patient has not used fluoroquinolones in the past 6 months 3, 2
• Patient is not from a urology department 3
• Patient has anaphylaxis to β-lactam antimicrobials 3

Avoid fluoroquinolones as empiric therapy if:

• Local resistance rates exceed 10% 3, 2
• Patient has recent fluoroquinolone exposure (within 6 months) 3, 2
• Other effective options are available 1

Parenteral Options for Severe Cases

When intravenous therapy is required (severe illness, inability to tolerate oral medications):

• Amoxicillin plus an aminoglycoside 3
• Second-generation cephalosporin plus an aminoglycoside 3
• Third-generation cephalosporin (e.g., ceftriaxone) intravenously 3

Transition to oral therapy when:

• Patient is hemodynamically stable 2
• Patient has been afebrile for at least 48 hours 2

Critical Pitfalls to Avoid

Do not treat for less than 7 days unless there is exceptional clinical response, as inadequate duration leads to recurrence and treatment failure 1, 2

Do not fail to obtain pre-treatment urine culture, as this complicates management if empiric therapy is ineffective 1, 2

Do not neglect evaluation for underlying urological abnormalities such as obstruction, incomplete voiding, or prostatic involvement, which may require specific management 3, 1, 2

Do not treat asymptomatic bacteriuria in men without specific indications, as this increases the risk of developing resistant organisms 2

Do not use antibiotics with high local resistance rates in your community, as this leads to treatment failure 2

Monitoring and Follow-Up

• Reassess clinical response after 48-72 hours of empiric therapy 2
• Adjust therapy based on culture and susceptibility results when available 2
• Monitor for resolution of symptoms and consider follow-up urine culture in complicated cases 3
• Address any identified underlying urological abnormalities to prevent recurrence 3