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

UTI Treatment in Males

For uncomplicated UTIs in males, treat with trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days as first-line therapy. 1, 2

First-Line Antibiotic Selection

• Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 7 days is the recommended first-line treatment for males with uncomplicated UTI according to the 2024 European Association of Urology guidelines 1, 2

• This regimen should only be used if local resistance rates for E. coli are below 20% 2

• Fluoroquinolones (ciprofloxacin or levofloxacin) can be prescribed as alternatives for 7 days, but only in accordance with local susceptibility testing 1, 2

• Avoid fluoroquinolones for empirical treatment if the patient has used them in the last 6 months or if local resistance exceeds 10% 1

Critical Distinction: All Male UTIs Are Considered Complicated

• Any UTI in a male is classified as a complicated UTI by definition, which explains why treatment duration differs from females 1

• The broader microbial spectrum in males includes E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., and Enterococcus spp. 1

• Urine culture and antimicrobial susceptibility testing should always be performed in males to guide therapy 3

Treatment Duration Considerations

• Standard treatment duration is 7 days minimum 1, 2, 3

• Extend treatment to 14 days when prostatitis cannot be excluded, which is a common clinical challenge in males with UTI symptoms 1, 2

• The longer duration accounts for potential prostatic involvement, as distinguishing between cystitis and prostatitis can be difficult clinically 3

Severe Presentations Requiring Hospitalization

• Initiate parenteral therapy with IV antibiotics (ciprofloxacin, levofloxacin, ceftriaxone, cefepime, or piperacillin-tazobactam) if the patient appears systemically ill or has pyelonephritis 2

• For complicated UTI with systemic symptoms, use combination therapy: amoxicillin plus an aminoglycoside, a second-generation cephalosporin plus an aminoglycoside, or an IV third-generation cephalosporin 1

• Once the patient is hemodynamically stable and afebrile for at least 48 hours, consider switching to oral therapy to complete a 7-14 day course 1

Common Pitfalls to Avoid

• Do not treat males with the short 3-5 day courses used for uncomplicated cystitis in women—this is inadequate and risks treatment failure 1

• Do not use fosfomycin or nitrofurantoin as first-line agents in males—these are specifically recommended only for women with uncomplicated cystitis 1

• Always consider urethritis and prostatitis in the differential diagnosis when males present with UTI symptoms, as this affects treatment duration and antibiotic choice 3

• If symptoms persist or recur after initial treatment, perform repeat culture and treat for 7 days with a different antimicrobial agent, assuming the organism is not susceptible to the original agent 1

Post-Treatment Management

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

• However, if symptoms persist or recur, obtain repeat culture and susceptibility testing before retreatment 1