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

Management of Urinary Tract Infections in Males

Initial Diagnostic Approach

All UTIs in males should be treated as complicated infections, and urine culture with susceptibility testing must be obtained before initiating antibiotics. 1, 2

• Males with UTI symptoms require mandatory urine culture and susceptibility testing to guide antibiotic selection, as antimicrobial resistance is more common than in uncomplicated UTIs 1, 2
• The microbial spectrum is broader in male UTIs, including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1
• Assess for systemic symptoms (fever, chills, rigors) to determine if parenteral therapy is needed 1, 2
• Evaluate for underlying urological abnormalities (obstruction, incomplete voiding, prostatic involvement) as these are common in male UTIs 2, 3

First-Line Empiric Antibiotic Selection

For Oral Therapy (Afebrile, No Systemic Symptoms)

Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily is the preferred first-line agent for male UTI when fluoroquinolones should be avoided. 2, 3, 4

• TMP-SMX 160/800 mg twice daily for 14 days is recommended when prostatitis cannot be excluded (which applies to most initial presentations) 2, 3, 4
• Ciprofloxacin 500-750 mg twice daily for 7-14 days is an alternative first-line option, but only if local fluoroquinolone resistance is <10% AND the patient has not used fluoroquinolones in the past 6 months 2, 3
• Levofloxacin 750 mg once daily for 5-7 days is another fluoroquinolone option with similar restrictions 2
• Avoid fluoroquinolones as first-line agents due to FDA warnings about disabling and serious adverse effects, creating an unfavorable risk-benefit ratio 3

Alternative Oral Agents

• Cefpodoxime 200 mg twice daily for 10 days is an effective oral cephalosporin alternative 2, 3
• Ceftibuten 400 mg once daily for 10 days is another oral cephalosporin option 2, 3
• Amoxicillin-clavulanate (Augmentin) should NOT be used as first-line empiric therapy due to high rates of persistent resistance (54.5% in E. coli) 3

For Parenteral Therapy (Systemic Symptoms or Severe Illness)

• Amoxicillin plus aminoglycoside 1, 2
• Second-generation cephalosporin plus aminoglycoside 1, 2
• Third-generation cephalosporin as monotherapy 1, 2

Treatment Duration

The standard treatment duration is 14 days when prostatitis cannot be excluded, which is the case in most initial male UTI presentations. 1, 2, 3

Evidence for Shorter Duration

• A 7-day course may be considered ONLY if the patient becomes afebrile within 48 hours and shows clear clinical improvement 1, 2, 3
• A high-quality 2021 randomized controlled trial demonstrated that 7 days of ciprofloxacin or TMP-SMX was noninferior to 14 days in afebrile men (symptom resolution: 93.1% vs 90.2%) 5
• However, a subgroup analysis showed 7-day ciprofloxacin was inferior to 14-day therapy for short-duration clinical cure in complicated UTI (86% vs 98%) 3
• A 2019 observational study found no clinical benefit to treating longer than 7 days in men without complicating conditions 6

Clinical Decision Algorithm for Duration

• 14 days: When prostatitis cannot be excluded (most cases), presence of urological abnormalities, immunocompromise, or unclear clinical response 1, 2, 3
• 7 days: Only for afebrile men who become afebrile within 48 hours with clear clinical improvement and no complicating conditions 1, 2, 5

Management of Multidrug-Resistant Organisms

For methicillin-resistant E. coli or other multidrug-resistant organisms:

• Ceftazidime-avibactam 2.5 g three times daily for 14 days 2, 3
• Meropenem-vaborbactam 2 g three times daily for 14 days 2, 3
• Cefiderocol 2 g three times daily for 14 days 2, 3

Special Considerations

Catheter-Associated UTI

• Remove or change the catheter when possible 1
• Mortality rate is approximately 10% for catheter-associated UTI 2

Nitrofurantoin in Males

• Nitrofurantoin is a valuable treatment option for male UTI only when systemic symptoms are absent 7
• Cannot be used for UTIs with systemic symptoms or suspected prostate involvement 7
• Approximately one-third of men may require a second course of antibiotics within 60-90 days 7

Asymptomatic Bacteriuria

• Do NOT treat asymptomatic bacteriuria in men, as this increases the risk of symptomatic infection and bacterial resistance 2, 3

Critical Pitfalls to Avoid

• Failing to obtain urine culture before starting antibiotics complicates management if empiric therapy fails 1, 2, 3
• Using fluoroquinolones empirically when local resistance rates exceed 10% or the patient used them in the past 6 months 1, 2, 3
• Not considering prostatitis as a complication, which requires the full 14-day treatment course 1, 2, 3
• Undertreating duration leads to persistent or recurrent infection, particularly when prostate involvement is present 2, 3
• Not addressing underlying anatomical or functional abnormalities that contribute to infection 1, 3
• Using amoxicillin-clavulanate empirically given high resistance rates (54.5%) 3

Follow-Up Management

• Tailor therapy based on culture and susceptibility results once available 1, 2
• Consider imaging studies if recurrent infections occur to rule out anatomical abnormalities 1
• Management of underlying urological abnormalities is mandatory alongside antibiotic therapy 1