What is the recommended treatment for a male urinary tract infection?

Treatment of Male Urinary Tract Infections

First-Line Antibiotic Recommendation

Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 14 days is the preferred first-line treatment for male UTIs. 1, 2

Treatment Algorithm

Initial Assessment and Culture

• Obtain urine culture and susceptibility testing before initiating antibiotics to guide potential therapy adjustments, as this is mandatory for optimal management. 1
• Perform a digital rectal examination to evaluate for prostate involvement, as prostatitis cannot be excluded in most male UTI presentations. 1
• All UTIs in males are classified as complicated infections due to anatomical factors and the inability to exclude prostatic involvement at initial presentation. 1

First-Line Oral Options (in order of preference)

1. Trimethoprim-sulfamethoxazole (TMP-SMX)

• Dosing: 160/800 mg orally twice daily for 14 days 1, 2
• Targets common uropathogens including E. coli, Klebsiella, Enterobacter, and Proteus species 1
• Should not be used if local resistance exceeds 20% 1

2. Fluoroquinolones (when TMP-SMX cannot be used)

• Ciprofloxacin 500 mg orally twice daily for 14 days 1
• Levofloxacin 750 mg once daily for 14 days 1, 3
• Only use when local resistance rates are <10% and the patient has not used fluoroquinolones in the past 6 months 1
• The FDA has issued warnings about disabling and serious adverse effects, creating an unfavorable risk-benefit ratio for uncomplicated infections 1

3. Oral Cephalosporins (second-line alternatives)

• Cefpodoxime 200 mg twice daily for 10-14 days 1
• Ceftibuten 400 mg once daily for 10-14 days 1
• Cephalexin 500 mg twice daily for 14 days is classified as an inferior alternative agent 1

Treatment Duration: Critical Decision Point

Standard duration is 14 days when prostatitis cannot be excluded, which applies to most male UTI presentations. 1, 2

A shorter 7-day course may be considered ONLY if:

• The patient becomes afebrile within 48 hours AND shows clear clinical improvement 1
• However, recent high-quality evidence demonstrates that 7-day ciprofloxacin therapy was inferior to 14-day therapy for short-term clinical cure in men (86% vs 98%, p=0.025) 1
• Despite one 2021 randomized trial showing noninferiority of 7-day treatment in afebrile men 4, subgroup analysis revealed lower cure rates with shorter duration 1

Parenteral Therapy for Severe Presentations

Hospitalize and initiate IV antibiotics if the patient has systemic signs (fever, rigors, hypotension, or appears toxic). 1

Initial IV options:

• Ceftriaxone 1-2 g IV once daily 1
• Second-generation cephalosporin plus an aminoglycoside 1
• Administer an initial IV dose of a long-acting parenteral antimicrobial before transitioning to oral therapy, even if planning oral treatment 1

Special Populations

Men with recent urinary tract instrumentation or surgery:

• Select antimicrobial regimens that provide broader coverage of gram-negative enteric organisms (E. coli, Klebsiella, Proteus) 1
• Higher risk of resistant or atypical pathogens in this setting 1

Epididymitis considerations:

• If likely gonococcal/chlamydial: Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 2
• If likely enteric organisms: Ofloxacin 300 mg orally twice daily for 10 days 2
• Add bed rest, scrotal elevation, and analgesics until fever and inflammation subside 2

Multidrug-Resistant Organisms

For methicillin-resistant E. coli and Proteus:

• Ceftazidime-avibactam 2.5 g IV three times daily for 14 days 1
• Meropenem-vaborbactam 2 g IV three times daily for 14 days 1
• Cefiderocol 2 g IV three times daily 1

Oral step-down options after clinical improvement (if susceptible):

• Levofloxacin 750 mg once daily for 14 days 1
• Ciprofloxacin 500 mg twice daily for 14 days 1

Critical Pitfalls to Avoid

• Do NOT use fluoroquinolones as first-line agents due to FDA warnings about serious adverse effects and unfavorable risk-benefit ratio. 1
• Do NOT treat asymptomatic bacteriuria in men, as this increases the risk of symptomatic infection and bacterial resistance. 1
• Do NOT fail to obtain urine culture before starting antibiotics, as this complicates management if empiric therapy fails. 1
• Do NOT use inadequate treatment duration (less than 7 days), as this leads to persistent or recurrent infection, particularly when prostate involvement is present. 1
• Do NOT use amoxicillin-clavulanate (Augmentin) as first-line empiric therapy, as high rates of persistent resistance (54.5%) have been documented in E. coli UTI cohorts. 1
• Do NOT ignore underlying urological abnormalities such as obstruction, incomplete voiding, or prostatic involvement, as these lead to recurrent infections. 1

Follow-Up and Monitoring

• Reassess clinical response at 48-72 hours; if the patient remains febrile or symptomatic, obtain repeat culture and consider imaging. 1
• Failure to improve within 3 days requires reevaluation of both the diagnosis and therapy. 2
• Adjust therapy based on culture results when the organism shows resistance to empiric treatment. 1
• Evaluate for structural or functional urinary tract abnormalities if infection recurs or persists despite appropriate therapy. 1
• Swelling and tenderness that persist after completion of antimicrobial therapy should be evaluated comprehensively. 2