In a male patient who has completed a 14‑day course of antibiotics for a presumed urinary tract infection, with persistent symptoms and a negative urine culture after the first course, should I continue the remaining 12 days of antibiotic therapy or discontinue it?

Discontinue the Remaining Antibiotic Course

You should instruct the patient to discontinue the remaining 12 days of antibiotic treatment immediately. With a negative urine culture after 14 days of antibiotics and resolution of the infection, continuing antibiotics provides no benefit and only increases the risk of antimicrobial resistance and adverse effects 1.

Rationale for Discontinuation

Evidence Supporting Shorter Courses in Male UTIs

• The American College of Physicians emphasizes that prolonged antibiotic use beyond symptom resolution does not reduce resistance—in fact, resistance is a documented side effect of prolonged antibiotic use due to natural selection pressure 1.
• For complicated UTIs (which includes all male UTIs), a 7-day course is sufficient for patients who are hemodynamically stable and afebrile for at least 48 hours 2.
• The standard 14-day recommendation for males exists primarily when prostatitis cannot be excluded 2, 3. However, your patient has already completed 14 days, which addresses this concern.

The Negative Culture Changes Everything

• A negative urine culture after treatment indicates bacterial eradication 4.
• Continuing antibiotics when there is no bacterial growth serves no therapeutic purpose and only exposes the patient to unnecessary risks 1.
• The culture result is the gold standard for detecting urinary tract infection, and its negativity confirms treatment success 4.

Understanding Persistent Symptoms

Residual Symptoms Do Not Equal Active Infection

• Persistent mild urinary symptoms after bacterial eradication typically represent residual mucosal inflammation, not treatment failure 3.
• These symptoms commonly resolve spontaneously within days to weeks after completing appropriate antibiotic therapy 3.
• Dysuria that improves with hydration and worsens with concentrated urine is characteristic of post-infectious irritation rather than ongoing infection 3.

Management of Residual Symptoms

• Counsel the patient to maintain aggressive hydration (at least 2-3 liters of fluid daily) to dilute urine and reduce irritative voiding symptoms 3.
• Reassure the patient that mild persistent symptoms are expected and do not indicate treatment failure when the culture is negative 3.
• Symptoms should continue to improve over the next 1-2 weeks without additional antibiotics 3.

Critical Pitfalls to Avoid

Do Not Default to Longer Courses

• Many physicians default to 10-day courses regardless of the condition, but this practice is not evidence-based 1.
• Even infectious disease subspecialists do not consistently recommend short-course treatment, but the evidence clearly supports it 1.
• There is no evidence that taking antibiotics beyond symptom resolution reduces antibiotic resistance 1.

Recognize the Harms of Overtreatment

• Antimicrobial overuse causes adverse events in up to 20% of patients, ranging from allergic reactions to Clostridioides difficile infections 1.
• Prolonged antibiotic exposure increases selection pressure for resistant organisms 1.
• The incidence of resistant infections is 6.1 per 10,000 person-days after receipt of antibiotics 1.

When to Reassess

Red Flags Requiring Further Evaluation

• If symptoms worsen or new symptoms develop (fever, flank pain, hematuria), repeat urine culture and clinical assessment 3.
• If symptoms persist beyond 2-3 weeks after stopping antibiotics, consider alternative diagnoses such as chronic prostatitis, urethritis, or non-infectious causes 5.
• Do not empirically restart antibiotics without repeat culture data if symptoms recur 3.

Follow-Up Recommendations

• Schedule follow-up in 2-3 weeks to ensure symptom resolution 3.
• Educate the patient about signs of recurrent infection that would warrant immediate re-evaluation 3.
• Consider urological evaluation if recurrent infections occur, as underlying anatomical or functional abnormalities may complicate male UTIs 6, 4.