What is the recommended treatment for a male patient with a urinary tract infection (UTI)?

Treatment of Urinary Tract Infections in Adult Males

Classification and Diagnostic Approach

All UTIs in adult males should be classified as complicated UTIs by definition, and urine culture with susceptibility testing must be obtained before initiating antibiotics. 1, 2, 3

• Male gender itself is considered a complicating factor regardless of other anatomical or functional abnormalities 2
• The microbial spectrum is broader than in female uncomplicated UTIs, commonly including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1, 3
• Antimicrobial resistance is more likely in male UTIs compared to uncomplicated female UTIs 1, 3
• Always evaluate for underlying urological abnormalities (obstruction, incomplete voiding, recent instrumentation) that require concurrent management 2
• Prostatitis must be considered in the differential diagnosis, as this directly affects treatment duration 2, 3

First-Line Antibiotic Therapy

For afebrile men with uncomplicated presentations, trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is the preferred first-line treatment. 4, 5

Oral First-Line Options:

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days is FDA-approved for UTI treatment and supported by high-quality evidence 6, 5
• Nitrofurantoin 100 mg twice daily for 7 days is an alternative first-line option 4, 7
• Ciprofloxacin 500-750 mg twice daily for 7 days may be used only if local fluoroquinolone resistance is <10% 1, 2
• Levofloxacin 750 mg once daily for 5-7 days is an alternative fluoroquinolone option when resistance rates permit 2

When to Avoid Fluoroquinolones:

• Do not use fluoroquinolones if local resistance exceeds 10% 2, 4
• Do not use fluoroquinolones if the patient has used them within the past 6 months 4, 3
• Fluoroquinolones should be reserved for more invasive infections due to FDA warnings about unfavorable risk-benefit ratios 4

Treatment Duration: 7 Days vs 14 Days

A 7-day course is non-inferior to 14 days for afebrile men without complicating conditions, but extend to 14 days when prostatitis cannot be excluded. 5, 8

• The highest quality evidence (2021 randomized controlled trial) demonstrated that 7 days of ciprofloxacin or trimethoprim-sulfamethoxazole was non-inferior to 14 days for symptom resolution (93.1% vs 90.2%, meeting noninferiority criteria) 5
• Recurrence rates were similar between 7-day and 14-day treatment (9.9% vs 12.9%, p=0.70) 5
• Extend treatment to 14 days when prostatitis cannot be excluded, as inadequate treatment of occult prostatitis leads to recurrence and treatment failure 1, 2, 3
• For patients who are hemodynamically stable and afebrile for at least 48 hours, 7-day treatment is appropriate 1, 3

Alternative Treatment Options

When first-line agents are contraindicated or resistance patterns preclude their use:

• Cefpodoxime 200 mg twice daily for 10 days 1, 2
• Ceftibuten 400 mg once daily for 10 days 1, 2
• For severe presentations requiring parenteral therapy initially, consider IV third-generation cephalosporin or aminoglycoside combinations, then transition to oral therapy once stable 3

Special Clinical Scenarios

Catheter-Associated UTI:

• Replace the catheter if it has been in place for ≥2 weeks before obtaining culture from the freshly placed catheter 2
• Remove catheters as soon as clinically appropriate to reduce infection risk 2, 3

Multidrug-Resistant Organisms:

• Aminoglycosides (gentamicin 5 mg/kg daily or amikacin 15 mg/kg daily) may be required 1, 2
• Consider carbapenems (meropenem 1 g three times daily, imipenem/cilastatin 0.5 g three times daily) only with early culture results indicating multidrug-resistant organisms 1

Monitoring and Adjustment

• Assess clinical response within 48-72 hours of treatment initiation 2, 3
• Tailor therapy based on culture and susceptibility results once available 1, 3
• If symptoms persist beyond 72 hours, obtain repeat culture and adjust antibiotics based on susceptibility testing 2

Critical Pitfalls to Avoid

• Do not automatically default to 14-day therapy for all male UTIs—this outdated approach increases antimicrobial resistance and adverse effects without improving outcomes in men with uncomplicated presentations 2, 5, 8
• Do not overlook prostatitis, as failure to extend treatment to 14 days when prostatitis is suspected leads to treatment failure and recurrence 2, 4, 3
• Do not use fluoroquinolones empirically if local resistance exceeds 10% or if the patient has recent fluoroquinolone exposure 2, 4
• Do not fail to obtain urine culture before starting antibiotics, as this is mandatory for all male UTIs 2, 3
• Do not neglect evaluation for underlying structural or functional abnormalities that require concurrent management 2, 4