From the Guidelines
Asymptomatic bacteriuria in males should not be treated with antibiotics except in specific circumstances, such as before urologic procedures that may cause mucosal bleeding, in pregnant patients, and in certain high-risk populations. The most recent and highest quality study, published in 2024 by the European Association of Urology 1, recommends that asymptomatic bacteriuria (ABU) should only be treated in cases of proven benefit for the patient to avoid the risk of selecting antimicrobial resistance and eradicating a potentially protective ABU strain. For males requiring treatment, appropriate antibiotic options include:
- Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3-5 days)
- Nitrofurantoin (100 mg twice daily for 5-7 days)
- Fluoroquinolones like ciprofloxacin (250-500 mg twice daily for 3-5 days) based on urine culture and sensitivity results. Before initiating treatment, a urine culture should be obtained to guide antibiotic selection. The rationale for avoiding routine treatment is that asymptomatic bacteriuria rarely progresses to symptomatic infection in most males, and unnecessary antibiotic use contributes to antimicrobial resistance while exposing patients to potential medication side effects without clear benefit. In elderly males with indwelling catheters, bacteriuria is nearly universal and treatment is particularly discouraged unless symptoms develop. Regular monitoring rather than treatment is the appropriate approach for most males with asymptomatic bacteriuria, as supported by previous guidelines from the Infectious Diseases Society of America 1 and the US Preventive Services Task Force 1.
From the Research
Treating Asymptomatic Bacteriuria in Males
- Asymptomatic bacteriuria is a common clinical condition that often leads to unnecessary treatment 2
- The incidence of asymptomatic bacteriuria increases with age and is more prominent in women than men 2
- In most scenarios, asymptomatic bacteriuria does not lead to urinary tract infections, and therefore, antibiotic treatment of asymptomatic bacteriuria has not been shown to improve patient outcomes 2, 3
- The Infectious Disease Society of America (IDSA) updated its asymptomatic bacteriuria management guidelines in 2019, which emphasized on the risks and benefits of treating the condition 2, 4
- Treating asymptomatic bacteriuria in individuals with diabetes, neutropenia, spinal cord injuries, indwelling urinary catheters, and so on has not been found to improve clinical outcomes 2, 4
- Unnecessary treatment is often associated with unwanted consequences including but not limited to increased antimicrobial resistance, Clostridioides difficile infection, and increased health care cost 2, 5
- There are few indications to treat asymptomatic bacteriuria, and inappropriate treatment contributes to the development of antimicrobial resistance 4
- The guidelines recommend against screening and treatment in healthy adults, including nonpregnant pre- and postmenopausal women, and patients with diabetes mellitus, long-term indwelling catheters, or spinal cord injuries 4
Specific Considerations for Males
- Limited observational studies support 7 to 14 days of therapy for acute urinary tract infection in men 6
- There is no specific guidance on treating asymptomatic bacteriuria in males, but the general principles of avoiding unnecessary treatment apply 2, 4, 3
- Antibiotics were more effective for bacteriological cure but also more adverse events developed in this group 3
- No differences were observed between antibiotics versus no treatment of asymptomatic bacteriuria for the development of symptomatic UTI, complications or death 3