What is the recommended treatment for a male patient with a urinary tract infection (UTI) presenting with dysuria (burning sensation) and nephrolithiasis (passing stones), whose urine culture shows susceptibility to Levofloxacin (levofloxacin)?

Treatment Recommendation for Male UTI with Nephrolithiasis and Levofloxacin-Susceptible Pathogen

For this male patient with UTI, dysuria, and kidney stones whose culture shows levofloxacin susceptibility, treat with levofloxacin 750 mg once daily for 5 days if symptoms are mild to moderate, or extend to 7-10 days if there is concern for upper tract involvement or delayed clinical response. 1, 2

Initial Management and Diagnostic Considerations

• Obtain imaging to rule out urinary obstruction given the history of passing stones, as obstructive pyelonephritis can rapidly progress to urosepsis and requires urgent intervention beyond antibiotics alone 1
• Ultrasound is the first-line imaging modality; consider CT scan if the patient remains febrile after 72 hours of treatment or shows clinical deterioration 1
• The presence of stones classifies this as a complicated UTI, which requires longer treatment duration than uncomplicated cystitis 1

Antibiotic Regimen Selection

Levofloxacin is an excellent choice given documented susceptibility, with the following dosing options:

For Mild to Moderate Illness (Patient Stable, No Sepsis):

• Levofloxacin 750 mg orally once daily for 5 days is FDA-approved and guideline-recommended for complicated UTI and acute pyelonephritis 1, 2, 3
• This high-dose, short-course regimen achieved 81% clinical success and 80% microbiological eradication in clinical trials 1, 2
• In patients with pyelonephritis specifically, levofloxacin 750 mg for 5 days showed 92.5% microbiologic eradication versus 93.4% with ciprofloxacin 500 mg twice daily for 10 days 4

For More Severe Illness or Delayed Response:

• Extend treatment to 7-10 days (or up to 14 days in males when prostatitis cannot be excluded) 1, 2
• The 2024 European Association of Urology guidelines recommend 7-day treatment for complicated UTI with prompt symptom resolution, and 10-14 days for delayed response 1

Route of Administration

• Start with oral therapy if the patient can tolerate oral intake and is hemodynamically stable 1
• Oral levofloxacin is rapidly absorbed and bioequivalent to IV formulation, allowing flexible transitions between routes 5, 6
• Consider initial IV therapy (levofloxacin 750 mg IV once daily) if the patient is severely ill, unable to take oral medications, or shows signs of sepsis, then switch to oral once clinically improved 1

Critical Management Points

Stone Management:

• Address the underlying stone disease concurrently, as retained stones can serve as a nidus for persistent infection and treatment failure 1
• Ensure adequate hydration to facilitate stone passage
• Urology consultation may be needed for stones causing obstruction or those unlikely to pass spontaneously

Monitoring Response:

• Expect clinical improvement within 48-72 hours of initiating appropriate therapy 1
• If fever persists beyond 72 hours, obtain imaging immediately to evaluate for complications such as abscess, obstruction, or emphysematous pyelonephritis 1

Follow-up Culture:

• While not routinely required for uncomplicated cases, consider test-of-cure urine culture 5-9 days after completing therapy given the complicated nature with stones 1

Important Caveats and Pitfalls

Avoid these common errors:

• Do not use moxifloxacin for UTI treatment due to uncertainty regarding effective urinary concentrations 1, 2
• Do not use shorter 3-day regimens in males or in the presence of upper tract symptoms/stones, as these are reserved only for women ≤65 years with mild catheter-associated UTI after catheter removal 1, 2
• Verify local fluoroquinolone resistance patterns are <10% before empiric use; if resistance exceeds this threshold, consider alternative agents 1, 2
• Be aware that the presence of stones increases risk of treatment failure and recurrence, so lower threshold for extended therapy duration 1

Resistance Considerations

• Levofloxacin maintains excellent activity against common uropathogens including E. coli, which is the most frequently isolated organism in pyelonephritis 4
• In catheterized patients, levofloxacin demonstrated superior microbiological eradication (79%) compared to ciprofloxacin (53%) 1, 2
• Reserve fluoroquinolones for situations where culture confirms susceptibility or other agents cannot be used to minimize resistance development 2

Special Consideration for Males

• In males, always consider possible prostatitis involvement, which would necessitate extending treatment to 14 days minimum 1
• Chronic bacterial prostatitis requires 28 days of fluoroquinolone therapy if present 3
• The presence of dysuria and stones makes isolated prostatitis less likely, but maintain clinical suspicion if symptoms persist